Do community-based health insurance schemes fulfil the promise of equity? A study from Burkina Faso

Objective: To examine whether the community-based health insurance (CBHI) scheme in Burkina Faso has been effective in providing equitable healthcare access to poor individuals, women, children and those living far from health facilities. Methods: We used the Nouna Health District Household Survey to collect panel data on 990 households during 2004-08. By applying a series of random effects regressions and using concentration curves, we first studied determinants of CBHI enrolment and then assessed differences in healthcare utilization between members and non-members. We studied differences with regard to rich and poor, men and women, children and adults and those living far vs those living close to health facilities. Findings: With regard to enrolment, we found that poor (odds ratio [OR] = 0.274) and children (OR = 0.456) were less likely to enrol while gender and distance were not significantly correlated to enrolment. In terms of utilization, poor (coefficient = 0.349), women (coefficient = 0.131) and children (coefficient = 0.190) with CBHI had higher utilization than the group without CBHI. We also found that there was no significant difference in utilization between members and non-members if they were living far from health facilities. Conclusion: The CBHI scheme in this case was only partially successful in achieving the equity objectives. This study advises policy makers in Burkina Faso and elsewhere, who see CBHI schemes as a silver bullet to achieve universal health coverage, to be mindful of the chronically low enrolment rates and more importantly the lack of equity across the various groups that this study has highlighted.